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Atul Gawande: Harvard School of Public Health Commencement Address

On June 4th, 2009, Atul Gawande delivered the following commencement address at the Harvard School of Public Health.

Thank you to the graduates, Dean Bloom, and Dean Frenk for asking me to speak to you on the occasion of graduation. It is an honor. I am grateful. And I would now like to proceed by ignoring you.

Instead, I would like to speak to your family and spouses and friends who have gathered here in celebration. I know they are proud. And I know that right now, in the midst of this terrible economy, they are asking themselves: “What the heck is a public health degree, anyway? What does anyone actually do with such a thing? Who are all these people?”

I am here to try to provide an answer for you. These are the people who are equipped better than anyone in our society to take on one of the central struggles of our time: how we live as mortal beings.

We have arrived at a difficult point in human history. For millennia before this moment in time, we had little knowledge of what to do to improve and sustain the health of human beings. The average longevity of a person was under forty years. The body and how it failed was largely a mystery.

The twentieth century, however, brought an age of remarkable discovery. In the last century, scientists have come to recognize more than sixty thousand different diseases and disorders that can afflict the human body, sixty thousand different ways the human body can fail. And they have discovered methods of prevention and treatment for nearly all them—if not to cure them, then at least to alleviate their worst harm and misery. That knowledge has ranged from sewage systems to intensive care technologies. And that knowledge is continuing to grow. But having discovered so much, we have hit a new problem—how to actually deliver on all that has been learned.

When Alexander Fleming discovered penicillin in 1928, it was, I think, a kind of fake out for the future of medicine and public health. Fleming gave us a simple injection that could cure numerous infectious conditions, and it led us to believe that managing disease would be easy and cheap. But eighty years later, we’ve found that the truth is far from this.

The reality came home to me a few years ago during a trip to India, my ancestral home. India has seen dramatic increase in longevity with economic advancements of recent decades—from an average life expectancy in the mid-forties at independence in 1947 to sixty-five years today. It has had a profound effect on the nature of disease. The number one killer is no longer diarrheal illness or respiratory infections. It is cardiovascular disease. Road accident injury is in the top five. Cancer is in the top ten. But they have a health system built for infectious disease. And on $20 per person per year for health care, it wasn’t clear how they could do anything about these problems.

My father comes from a small village in Maharashtra, 400 miles east of Mumbai. Most of his family is still there. He is one of thirteen brothers and sisters. They are farmers. Cotton, sugar cane, and a type of wheat called jowar are their cash crops. Drip irrigation has allowed them two crops a year, and that has provided a degree of prosperity. Malnutrition is no longer issue. They have malaria or a diarrheal illness, a cottage hospital nearby has been able to provide effective, basic care. But the villagers began to have problems that will seem quite familiar to us here—one uncle had his hip shattered in a motorcycle accident; another had high blood pressure and chest pains from heart disease; one cousin was disabled with kidney stones.

So for these kinds of problems they must travel to the government hospital in Nanded, seventy miles away. It is the lone public hospital serving a district of 1400 villages and 2.3 million people. It has 500 beds, three operating rooms and, I found when I visited, just nine general surgeons. (Imagine Kansas with just nine surgeons.) The surgeons arrive each morning to a crush of two hundred people pressing their way into clinic. And one of the puzzles for me in visiting there was how do the surgeons do it? How do they possibly take care of all the hernias and stab wounds, the appendicitis cases and tubercular abscesses—and sleep, live, survive themselves?

The answer, I figured, was triage. The clinic was like many you find in India. They were ovens in the heat of summer. The paint flaked off the walls in jagged strips. Each room had a metal desk, some chairs, a ceiling fan stirring, and at any given moment six, sometimes eight patients jockeying for attention. Among them was a silent, scared woman in her thirties who undid her saree when we took her behind a thin rag curtain to examine her and revealed a fist-sized tumor in her breast. It was fixed to the skin, an ominous sign. Before arriving in India, I had assumed that the complex, expensive treatment such advanced cancers require—chemotherapy, radiation, surgery—would be beyond the doctors capabilities and that the surgeons would send patients like her home to die.

But the surgeons did no such thing. It was unacceptable. Instead the surgeon on duty admitted the woman to the hospital and started her on chemotherapy that same afternoon himself. I have no idea how to safely administer chemotherapies. In the West, this is something considered so difficult only oncologists know how to do it. But Indian manufacturers produce cheap (often pirated) versions of most drugs, and everywhere I went in India, surgeons had learned how to dose and administer the cyclophosphamide, methotrexate, and fluorouracil themselves, in makeshift treatment rooms of benches and folding chairs. They made compromises out of necessity. But they got the patients through.

The same was true for the radiation the patients needed. If they had a working cobalt-60 unit, the kind of radiation therapy unit used in the United States in the 1950s, the surgeons planned and delivered the radiation themselves. If the tumor responded, they then performed surgery. It was textbook treatment devised by other means.

At every step, the surgeons did what they could. But the onslaught remained. I watched a single surgeon try to see ten to fifteen patients an hour in clinic. In one morning, he identified more patients who needed surgery than they had facilities or personnel for in a week. It was like this every day.

The needs of our world have shifted in ways that alter our conception of public health. There’s been an explosion of complex needs as much of the world’s population lives past infectious disease. Consider my field: 230 million people now undergo major surgery each year. The volume exceeds that of childbirth, but with death rates 10 to 100 times higher. And yet we still have two billion without access to essential surgery—for endangered childbirth, trauma, emergencies.

If we are to save lives and use health resources wisely, we have to think about our health systems in all their dimensions—how they cope with everything from malaria to surgery. For we’ve generated tremendous scientific knowledge but not the capacity to deliver on it reliably, safely, humanely, or equitably. Closing this gap is the work of public health. It has become the pivotal struggle of our era. And that has become true not only in the poorest parts of the world.

Recently, I helped care for a critically ill woman in her sixties here in Boston with severe abdominal pain from a bowel obstruction that ruptured her colon. She arrived in shock and renal failure. Then she had a heart attack. A simple injection was not going to help her.

There were several things that stuck with me about what was required to help her. First was that much of her worst troubles were preventable with knowledge that we have today but didn’t have just a few decades ago. She’d had high blood pressure, high cholesterol, and signs of heart disease that had gone untreated, and she’d had several weeks of abdominal pains that had gone unattended. She was now at death’s door. But, in our modern age, she didn’t have to be. Insurance coverage problems may have played a role. She’d not seen a physician in fifteen years. Our system had failed her even before she arrived.

A second thought occurred to me as we rushed her from the emergency department to the operating room, and that was that it wasn’t very long ago that we would have been unable to even try to help in this situation. Her problems were too complex. She was too sick. But techniques of anesthesia, surgery, cardiology, and intensive care had been perfected. Our greatest struggle now was less with knowing what to do than with knowing how to make it go right without errors. Indeed, it was public health people who discovered that errors in medicine have become as great a cause of avoidable harm and death in the United States as many diseases.

To try and save her, I operated to repair her ruptured colon, a cardiologist treated her heart attack, an intensivist managed her shock, and a vascular surgeon tried to rescue her foot, which became gangrenous and would have to be amputated. We managed to escape major errors, and a week later, amazingly, she was on the mend. But that was when we encountered one further problem.

It doesn’t take long after a case like hers to begin to wonder how well we are equipped to not just save people, but also to help them live. As we contemplated the possibility that she’d be able to leave the hospital, and considered that when she went home, she’d be unable to walk, unable to eat for months, and have a large open wound, someone asked: “Who’s going to be her doctor? Who’s going to take care of her?” The silence was deafening. Her care was too complex for a lone primary physician. But in our current, fragmented health system, we had no real mechanism, let alone incentives, to insure that all the specialists could function as a team and insure that nothing fell between the cracks, that we were all working in a common direction for her.

In the end, she didn’t make it out of the hospital. She got a simple pneumonia during her second week. That was simply too much for her. I wondered if we’d gone too far and only prolonged her suffering. And when we pronounced her dead with her family by her side, I realized that—here with this one patient, in this hospital right behind me, in the most technologically advanced country on the planet—we too were struggling with a system that is failing our people.

We have had a century of extraordinary scientific discovery about human health. But we have found ourselves with yawning gaps in our ability to provide it to people—here and around the globe. We have trouble managing its complexity, its costs, and its implications for everything from how countries should structure their health systems to how we as individuals should manage the end of life. Making it so the people of the world can live lives as free from disease and suffering as possible is the work of public health. And we have learned, it will require attention to everything from economics to the environment to technology and institutions.

These people sitting here today are the ones who will be providing that attention. They are lawyers, engineers, doctors, business people, statisticians, laboratory scientists, policy wonks. We even have musicians. And in coming here, they have sought to take the time to understand how to measure the problems of our world, how to innovate improvements, and how to bring people to implement them wherever they may be.

Leaders, someone once said, are those who seek to solve the hard problems. Who are these people graduating today, then?